Reinventing Radiology Reports in the Age of Value-Based Care

,

In a thorough review of the literature, these authors discuss current approaches and emerging initiatives to increase the understanding of radiology reports by referring physicians as well as patients.

Standard radiology reports often follow a narrative or free-form format, allowing the radiologist to highlight radiologic findings of importance while diminishing those insignificant to the clinical context. Unsurprisingly, researchers have noted that less than four percent of radiology reports are written at an eighth-grade level, with the average report requiring college-level reading skills.1 In the past, institutions have placed an embargo on radiology reports. While patients may request access to them, the embargo allowed referring providers a few days to review the report and discuss the results with the patients and their families.

However, with the widespread adoption of electronic health records (EHR) and the 2016 passage of the 21st Century Cures Act, patients now have unprecedented speed and access to their radiology reports. Quite often, patients will have read their reports before their referring providers. Since the 21st Century Cures Act, there has been a 78.3 percent spike in patient calls regarding radiology reports.2 Disruptive innovations and new legislation have pressured radiologists to provide reports that balance the clarity of information with manageable language for providers and patients.

Accordingly, let us take a closer look at the current concerns and preferences of physicians and patients on radiology reports, immediate solutions, such as structured reporting, patient summaries, and infographics to improve patient inclusivity, and long-term goals to redesign the traditional report and implement an interactive radiology report.

What Referring Physicians and Patients Prefer to See in Radiology Reports

Historically, patient concerns about radiology reports have centered around accessibility and comprehension. Most patients wanted their report as quickly as possible regardless of the result.3 Electronic health records and the Cures Act have primarily resolved this concern. The content of radiology reports remains a crucial barrier to comprehension. By analyzing patient discussions in online forums, Alarifi and colleagues categorized three major subthemes for the improvement of radiology reports: report representation, image utilization, and understanding.4 Patients wanted a well-formatted report with structured information and clear content display. The images needed to be clearly shown and appropriately adjusted for brightness and contrast to eliminate any ambiguity in visualization. Finally, patients wanted a better understanding of medical jargon and instructions and access to additional resources to aid their comprehension.

From the providers’ perspective, more than 90 percent of referring clinicians surveyed valued an itemized, structured report over ones provided in a free-form style.5 In practice, however, a survey of 265 United States radiologists found that only 51 percent used structured reporting consistently.6 Moreover, the referring providers often misinterpreted the radiology report similarly to patients despite being the intended audience. In a study performed by Rosenkrantz and colleagues, when radiologists used an expression other than “cyst” or “benign cyst” to describe low-risk incidental lesions, this resulted in increased alarm and higher follow-up by both the patient and referring physicians.7 The fact that referring providers have misunderstandings about radiology reports is a notable area for improvement.

Assessing the Pros and Cons of Structured Reporting

Structured reporting is not new in radiology. The most established form of structured reporting is the Breast Imaging Reporting and Data System (BI-RADS) format, which was developed to address concerns about confusing interpretations. Initiatives are already in place to aid radiologists in transitioning from free-form radiology reports. The RSNA Radiology Reporting Initiative developed a free library of templates (www.radreport.org/ ) based on best practices to enable consistent, high-quality reports.

The advantages of a structured reporting format are numerous. First and foremost, structured reporting reduces diagnostic errors. A checklist and systematic search pattern minimize cognitive biases arising from a radiologist’s “satisfaction of search,” in which a radiologist prematurely stops searching for additional diagnoses after finding the initial diagnosis.8 Quattrocchi and colleagues found a 28.5 percent increase in clinically significant extraspinal findings in structured reporting compared to free-form reporting.9 Reducing such cognitive biases can improve patient care and the overall report.

The systematic method also improves referring provider’s comprehension of the report. While physicians may be the intended audience for the radiology report, discrepancies between radiologists and referring clinicians arise due to non-standard terminology. Bosmans and colleagues found that 17 percent of referring providers found radiology reporting unnecessarily complicated.5 Structured report templates can prompt radiologists to incorporate critical findings with clinical conditions while reducing syntactic and semantic errors. A computed tomography (CT) coronary angiography study demonstrated such benefits when referring physicians’ comprehension improved with a structured report.10 In a separate pancreatic cancer study, a structured report improved surgeons’ confidence in tumor resectability.11 In this manner, referring providers can better utilize the radiologist’s expertise to enhance their clinical acumen.

Admittedly, structured reporting has its shortcomings. “Eye dwell problem,” or the tendency for the radiologist to focus on the word template rather than the imaging itself, has the potential to disrupt workflow.12 Complicated cases with multiple abnormalities may exacerbate this issue. In these cases, the disease process may render radiology insufficient in conveying all of the findings to the intended audiences. Direct communication with the referring provider or the patient could be necessary. A structured report’s utility can be helpful in organizing the findings and highlighting key areas of concern.

Perspectives on Making the Radiology Report More Patient-Friendly

While structured reporting may bridge the gap between radiologists and fellow clinicians, there is still a sizable disparity between the patient and the radiologist. This is where consumer-friendly supplementation can have an impact in complementing the radiology report.

Several methods of implementation are currently being tested. The most direct and simplistic solution is creating a “patient summary statement.” A radiologist would summarize the pertinent findings, briefly explain the clinical correlation, and inform patients with follow-up instructions in patient-friendly language.13 In a patient-centered section, the radiologist could focus the patient on areas of clinical concern and minimize potential distractions in the findings. Furthermore, the benefit is the increase of patient inclusivity without significant disruption to a radiologist’s workflow.

A more detailed, consumer-friendly report would be the creation of an infographic directed explicitly at the patient. Von Eckstaedt and colleagues at the University of Virginia redesigned the traditional radiology report with an infographic for lung cancer screening patients.14 The infographic provides brief information about low-dose CT scans, patient results, and follow-up instructions. More importantly, the report is filled with visual aids that correlate with the simplified language to improve patient comprehension.

Patients in the study had an overwhelmingly positive response with 65.2 percent preferring the infographic to the traditional report.14 Although this approach is more involved than a patient summary, consumer-friendly infographic reports can potentially organize complex and less structured data into a medium suitable for patient use. Conversely, routine radiology procedures may utilize a predesigned infographic template for multiple patients, thus, expediting workflow. Due to the novelty of the approach, the effects of infographics have not been quantified in the radiology literature at the time of this publication.

Exploring Future Directions for Radiology Reports

While patient summaries and infographics can increase patient inclusivity, the core content of a radiology report would remain inaccessible due to the technical, medically specific terminologies necessary for the precise, accurate, relevant description of image findings. Proposals for report redesign and interactive radiology reports seek to remedy that problem.

Based on suggestions and concerns from patients, Alarifi and colleagues sought to redesign a patient-friendly radiology report. The redesign included much of the previously mentioned solutions, including structured reporting, a patient summary section, and follow-up instructions. Two standouts of the redesign include the annotation of written findings and a correlating clinical imaging section.15

The clinical imaging section further enhances the written findings, using annotated diagrams with anatomical references as a visual aid. An impressive aspect of the imaging section is the personalized clinical context in which the patient’s radiography sits between “normal case” and “worst case” scenario reference images. The visual differences between the patient’s image and the clinical references allow the patients to examine their disease process without reading complicated medical jargon.

The reception to the redesigned radiology report was positive with more than 70 percent of respondents marking “agree” or “strongly agree” to the questions about understanding the report. Another notable aspect of the study was that improvements in the redesign were unrelated to age, gender, economic status, ethnicity, and health literacy.15 Utilizing clinical images to correlate the written findings may be a potential direction toward a more patient-friendly report. Additionally, referring providers may also use the annotated and reference images as a visual aid to enhance treatment discussions with patients and their families.

A redesigned radiology report may take some time before it is fully optimized to achieve a readily accessible level. There may also be multiple competing strategies individualized to different institutions before standardization.

Another proposed solution is an interactive radiology report like Scanslated.16 Kemp and colleagues' interactive web-based application uses natural language processing to annotate a patient radiology report. After a radiologist completes the report, the software processes it before making it available to the patient in 48 hours. The patient can log on to his or her account and review the patient-friendly report. Unlike many other annotated reports, a standout feature of Scanslated is its inclusion of animated diagrams.

The developers of Scanslated hope to improve patient education and health literacy through user interaction with the program. The pilot study did reveal a notable increase in engagement. Patients who opened the annotated links spent an average of 5.8 minutes compared to 1.8 minutes for those who just read the text.16 The pilot study also received positive responses with 85 percent of respondents believing the application improved their understanding.16 The advantage of natural language processing to annotate a report would be the rapid deployment of such services across different institutions and clinics.

Both studies demonstrated marked improvements in patients’ subjective understanding of the radiology report. While quantification and confirmation of patient knowledge are necessary to optimize the best approach to patient-centered reporting, the studies reaffirmed patients’ appetite for greater engagement and comprehension.

Recognizing The Opportunity with Emerging Patient Empowerment and Value-Based Care

Including patients as a new target audience for radiology reports presents an extraordinary opportunity for radiology. As health care shifts from volume-based to value-based care, patients increasingly take ownership of their health and engage in shared decision-making. Despite challenges, direct access and immediacy of radiology reports increase the visibility of radiologists as an integral part of the patient care process. Radiology reports play a vital role in patient autonomy as it is often an essential piece of data utilized by patients seeking second opinions or consultations.

Therefore, greater adoption of structured reporting and the tailoring of patient-centric subsections are immediate and impactful methods to promote patient inclusivity and improve peer clinician communication. Referring physicians can more readily learn from the radiologist’s expertise, and patients can now receive concrete and actionable plans from their radiology reports. Importantly, this promotes a greater connection and interaction between the patient and his or her health-care team.

The future steps of redesigning and utilizing interactive radiology reports would continue to break down barriers to health-care access and literacy. The current push for patient-centered radiology reports creates a unique opportunity for radiologists to elicit the needs of patients directly. It also allows patients to shape the delivery and communication of their health information. While the development and adoption of redesigned reports are still in the early stages, the overwhelming support from patients offers clear assurances in favor of patient-centered radiology reports.

References

1. Martin-Carreras T, Cook TS, Kahn Jr CE. Readability of radiology reports: implications for patient-centered care. Clin Imaging. 2019;54:116-120.

2. Mehan Jr WA, Gee MS, Egan N, Jones PE, Brink JA, Hirsch JA. Immediate radiology report access: a burden to the ordering provider. Curr Probl Diagn Radiol. 2022;51(5):712-716.

3. Basu PA, Ruiz-Wibbelsmann JA, Spielman SB, Van Dalsem 3rd VF, Rosenberg JK, Glazer GM. Creating a patient-centered imaging service: determining what patients want. AJR Am J Roentgenol. 2011;196(3):605-10.

4. Alarifi M, Patrick T, Jabour A, Wu M, Luo J. Understanding patient needs and gaps in radiology reports through online discussion forum analysis. Insights Imaging. 2021;12(1):50.

5. Bosmans JML, Weyler JJ, De Schepper AM, Parizel PM. The radiology report as seen by radiologists and referring clinicians: results of the COVER and ROVER surveys. Radiology. 2011;259(1):184-95.

6. Powell DK, Silberzweig JE. State of structured reporting in radiology, a survey. Acad Radiol. 2015;22(2):226-33.

7. Rosenkrantz AB. Differences in perceptions among radiologists, referring physicians, and patients regarding language for incidental findings reporting. AJR Am J Roentgenol. 2017;208(1):140-143.

8. Lee CS, Nagy PG, Weaver SJ, Newman-Toker DE. Cognitive and system factors contributing to diagnostic errors in radiology. AJR Am J Roentgenol. 2013;201(3):611-7.

9. Quattrocchi CC, Giona A, Di Martino AC, et al. Extra-spinal incidental findings at lumbar spine MRI in the general population: a large cohort study. Insights Imaging. 2013;4(3):301-8.

10. Ghoshhajra BB, Lee AM, Ferencik M, et al. Interpreting the interpretations: the use of structured reporting improves referring clinicians' comprehension of coronary CT angiography reports. J Am Coll Radiol. 2013;10(6):432-8.

11. Brook OR, Brook A, Vollmer CM, Kent TS, Sanchez N, Pedrosa I. Structured reporting of multiphasic CT for pancreatic cancer: potential effect on staging and surgical planning.Radiology. 2015;274(2):464-72.

12. Babu AS, Brooks ML The malpractice liability of radiology reports: minimizing the risk. Radiographics. 2015;35(2):547-54.

13. Gunn AJ, Gilcrease-Garcia B, Mangano MD, Sahani DV, Boland GW, Choy G. JOURNAL CLUB: structured feedback from patients on actual radiology reports: a novel approach to improve reporting practices. AJR Am J Roentgenol. 2017;208(6):1262-1270.

14. Von Eckstaedt HV, Kitts B, Swanson C, Hanley M, Krishnaraj A. patient-centered radiology reporting for lung cancer screening. J Thorac Imaging. 2020;35(2):85-90.

15. Alarifi M, Patrick T, Jabour A, Wu M, Luo J. Designing a consumer-friendly radiology report using a patient-centered approach. J Digit Imaging. 2021;34(3):705-716.

16. Kemp J, Short R, Bryant S, Sample L, Befera N. Patient-friendly radiology reporting -- implementation and outcomes. J Am Coll Radiol. 2022;19(2 Pt B):377-383.